ImprimisRx Ophthalmic Topical Order Form

To submit this form, ensure all the required fields are completed with accurate information. Once filled out, you can submit the form via fax to the number provided on the form (855-405-4669). Alternatively, you can email the completed form to order@imprimisrx.com. Ensure you have all necessary signatures and verifications before sending. For any queries or assistance, contact ImprimisRx customer support at 844-446-6979.

Ensure to submit this form by the designated dates to avoid delays in medication orders. Check with your pharmacy or healthcare provider for specific submission deadlines in 2024 and 2025.

The purpose of the ImprimisRx Ophthalmic Topical Order Form is to facilitate the ordering of customized compounded medications for patients requiring specific ophthalmic treatments. This form ensures that all necessary patient information, medical needs, and prescriber details are captured accurately for seamless processing and delivery of medications. Healthcare providers use this form to streamline their ordering process, ensuring patients receive their required treatments in a timely manner. The form requires detailed patient information, including contact details and shipping preferences. It also provides a comprehensive list of available compounded medications and options for selecting medical necessities. The prescriber must verify and sign the form, attesting to the medical necessity of the order and providing their contact and payment information. By using this form, healthcare providers can ensure compliance with state and federal documentation requirements, maintain accurate patient records, and facilitate efficient communication with pharmacies. This ultimately helps in delivering high-quality care to patients needing specialized ophthalmic medications.

• 1. Patient Information: Includes fields for the patient's name, date of birth, gender, contact details, and address.
• 2. Shipping Options: Allows selection of shipping methods such as FedEx Overnight, 2 Day, Ground, or ship to office/patient.
• 3. Medications and Medical Necessity: Lists available medications with options to indicate medical necessity and dosage.
• 4. Instructions for Use: Provides fields for quantity, refills, and administration details.
• 5. Prescriber Verification: Contains fields for the prescriber's name, contact details, license number, and signature.
• 6. Payment Details: Includes fields for payment method, credit card information, and billing address.

Failure to submit this form can result in delays or the inability to fulfill medication orders. It's crucial to complete and submit the form promptly to ensure timely delivery and patient care.

• Delay in Medication: Patients may experience delays in receiving their necessary ophthalmic treatments.
• Incomplete Order Processing: The pharmacy may not be able to process the order without complete and accurate information.
• Compromised Patient Care: Delayed or missing medications can impact the quality of care provided to patients.
• Non-compliance: Healthcare providers may fail to comply with regulatory requirements.

• 1. New Medication Orders: Use this form to place orders for new compounded ophthalmic medications for patients.
• 2. Refill Requests: Use this form to request refills for existing ophthalmic prescriptions.
• 3. Medical Necessity Documentation: Document the medical necessity of specific compounded medications for patient care.
• 4. Prescriber Verification: Prescribers can verify and sign off on the medications ordered for their patients.
• 5. Shipping Instructions: Specify shipping preferences to ensure medications are delivered to the correct location.